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Journal Club
Alcohol, Other Drugs, and Health: Current Evidence
May-June 2007
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Featured Article
Persistent pain is associated with
substance use after detoxification:
a prospective cohort analysis
Larson MJ, et al. Addiction. 2007;(Online Early Articles):
doi: 10.1111/j.1360-0443.2007.01759.x.
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Study Objective
To examine whether persistent pain is
associated with…
•an increased odds of substance useafter detoxification
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Study Design
•This was a secondary analysis of 397 subjectswho had participated in a randomized clinical trial.
•All subjects had been admitted to an urban,residential drug and alcohol detoxification unit andinterviewed periodically over 24 months.
•Researchers assessed pain with the SF-36 HealthSurvey and substance use with the AddictionSeverity Index.
•Analyses were adjusted for potential confounders.
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Assessing Validity of anArticle about Prognosis
•Are the results valid?
•What are the results?
•How can I apply the results topatient care?
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Are the Results Valid?
•Was the sample representative?
•Were the subjects sufficiently homogeneous withrespect to prognostic risk?
•Was follow-up sufficiently complete?
•Were objective and unbiased outcome criteriaused?
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Was the sample representative?
•The sample was a cohort of adults admitted to an urban,residential alcohol and drug detoxification unit.
–It is unclear how many were referred; 470 of 642consented to enroll in the randomized trial.
•Because the primary study evaluated efforts to linkpatients to primary care after detoxification, patients whoalready had a primary care provider were excluded.
–This somewhat limits the representativeness of the sample.
•Other important exclusions included being pregnant, notbeing able to list 3 contacts, and not providing consent.
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Were the subjects sufficiently homogeneouswith respect to prognostic risk?
All patients received standard detoxificationservices.
Randomization occurred after detoxification,indicating that the risk of relapse should havebeen similar in all subjects.
No information was provided on the distributionof pain disorders across the two study arms.
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Was follow-upsufficiently complete?
•Subjects were assessed every 6 months over24 months.
•69% completed the 24-month interview.
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Were objective and unbiasedoutcome criteria used?
•Self-reported outcomes (in the past 30 days) wereassessed with the Addiction Severity Index and included...
–Heavy alcohol use (>3 drinks on at least 1 day orintoxication)
–Cocaine use
–Heroin/opioid use
–Any substance use (i.e., heavy alcohol use or illicit use ofcocaine or opioids)
•There was no mention of blinding to the primaryindependent variable of pain as assessed by the SF-36.
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What are the Results?
•How likely are the outcomes over time?
•How precise are the estimates oflikelihood?
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How likely are the outcomes over time?
Results (prospectively assessed):
•16% reported persistent pain (moderate-to-higher painlevels at all available interviews) in the 24 months afterdetoxification.
•Subjects reporting persistent pain were more likely thanthose with mild or no pain to have (in the past 30 days atthe 24-month follow-up)…
–used any substance (odds ratio [OR], 4.21);
–used heroin/opioids not prescribed for pain (OR, 5.36);
–consumed >3 drinks on at least 1 day or been intoxicated (OR, 2.15);
–used cocaine (OR, 2.05).
•All results, except for cocaine use, were significant.
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How precise are the estimatesof likelihood?
•Confidence Intervals [CI] are wide:
–For any substance use: OR, 4.21; 95% CI, 1.90-9.33
–For heroin/opioid use: OR, 5.36; 95% CI, 2.09-13.75
–For heavy alcohol use: OR, 2.15; 95% CI, 1.03-4.51
–For cocaine use: OR, 2.05; 95% CI, 0.91-4.62
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How Can I Apply the Results toPatient Care?
•Were the study patients and theirmanagement similar to those in my practice?
•Was the follow-up sufficiently long?
•Can I use the results in the management ofpatients in my practice?
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Were the study patients similarto those in my practice?
•Subjects are fairly representative of patientsreceiving residential detoxification.
•However, patients with existing primary careproviders were excluded.
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Was the follow-upsufficiently long?
•Follow-up occurred over 24 months.
•This timeframe is clinically important.
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Can I use the results in themanagement of patients in my practice?
•These results should be primarily used to heightenclinicians’ concern about the risk of relapse to anysubstance–particularly opioids or alcohol–in theirpatients discharged from detoxification.
•Next steps should include exploring variousstrategies (nonopioid vs. opioid) for treating pain inpatients with persistent complaints of pain afterdetoxification.